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Financial Incentives and Physician Commitment to Guideline-Recommended Hypertension Management
Sylvia J. Hysong, PhD; Kate Simpson, MPH; Kenneth Pietz, PhD; Richard SoRelle, BS; Kristen Broussard Smitham, MBA, MA; and Laura A. Petersen, MD, MPH
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Financial Incentives and Physician Commitment to Guideline-Recommended Hypertension Management

Sylvia J. Hysong, PhD; Kate Simpson, MPH; Kenneth Pietz, PhD; Richard SoRelle, BS; Kristen Broussard Smitham, MBA, MA; and Laura A. Petersen, MD, MPH
Financial incentives may not be strong enough to influence physician goal commitment to guideline-recommended hypertension care when providers attribute performance to forces beyond their control.
Objectives: To examine the impact of financial incentives on physician goal commitment to guideline-recommended hypertension care.

Study Design: Clinic-level cluster-randomized trial with 4 arms: individual, group, or combined incentives, and control.

Methods: A total of 83 full-time primary care physicians at 12 Veterans Affairs medical centers completed web-based surveys measuring their goal commitment to guideline-recommended hypertension care every 4 months and telephone interviews at months 8 and 16. Intervention arm participants received performance-based incentives every 4 months for 5 periods. All participants received guideline education at baseline and audit and feedback every 4 months.

Results: Physician goal commitment did not vary over time or across arms. Participants reported patient nonadherence was a perceived barrier and consistent follow-up was a perceived facilitator to successful hypertension care, suggesting that providers may perceive hypertension management as more of a patient responsibility (external locus of control).

Conclusions: Financial incentives may constitute an insufficiently strong intervention to influence goal commitment when providers attribute performance to external forces beyond their control.

(Am J Manag Care. 2012;18(10):e378-e391)
Financial incentives may constitute an insufficiently strong intervention to influence goal commitment when providers attribute performance to external forces beyond their control.

  • Among survey participants, patient nonadherence was perceived to be outside provider control and a barrier to successful hypertension care; consistent follow-up was perceived to be a facilitator.

  • Designers of pay-for-performance programs for clinicians should consider rewarding clinicians for behaviors and outcomes under their direct control, as well as for behaviors and outcomes for which individual goal commitment could increase, in order to maximize the likelihood that the incentive will result in a positive clinical outcome.
Use of financial incentives as a tool to improve clinical quality is a growing trend in American healthcare1; insurers and hospitals are using pay-for-performance programs to change clinician behavior and improve quality of care. Importantly, the Affordable Care Act of 2010 will implement a Value-Based Purchasing Program in 2012 that offers financial incentives to hospitals based on the quality of care provided. Consequently, understanding how to incentivize providers’ behavior effectively may significantly improve quality of care.

Some researchers have identified an association between financial incentives and improved care, though these data are limited and additional evidence using rigorously designed methods is needed.2-7 In the largest randomized controlled trial to our knowledge about the impact of financial incentives on quality of care, preliminary findings by Petersen and colleagues8 were that financial incentives improved blood pressure control or an appropriate clinical response to uncontrolled blood pressure, suggesting that financial incentives could impact care if designed correctly. However, we are not aware of any healthcare studies to date that examined the mechanism by which financial incentives may act to change provider behavior. Without this knowledge, it is very difficult to design effective financial incentive programs.


Research from both industrial/organizational psychology and management has demonstrated that financial incentives are linked to behavior resulting from setting and committing to a goal.9-13 According to Locke and Latham’s theory of goal setting and task motivation, setting goals positively impacts performance; goal commitment (ie, the psychological commitment to achieving a goal) moderates this relationship such that the greater the goal commitment, the stronger the impact of setting goals will be on performance.14 Although increasing goal commitment is mostly accomplished via intrinsic means, such as increasing self-efficacy or expectancy of task attainment, financial incentives present one of the few extrinsic tactics an organization can use to improve goal commitment (and subsequently performance), particularly if goals are assigned rather than self-set.8 The Figure displays these relationships.

Studies have shown that financial incentives are unrelated to performance once goal setting is accounted for10,12,14 and that goal commitment is the key driver of goal-setting behavior for both self-set and assigned goals. Goal commitment has also been linked to increased planning activities, which in turn lead to improved performance, much like intention is linked to actual behavior.15,16 We therefore hypothesized that financial incentives would significantly impact provider goal commitment to guideline-recommended hypertension management. We are not aware of any studies in healthcare settings exploring the relationship between financial incentives and goal commitment, nor of the impact of different financial incentive configurations (eg, group vs individual) on goal commitment.



This mixed-methods study is nested within a larger clusterrandomized controlled trial evaluating the impact of financial incentives on adherence to guidelines established in the Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 7) in the primary care setting.17 Primary care clinics within 12 geographically diverse Veterans Affairs (VA) medical centers were randomly assigned to 1 of 4 study arms: (1) audit and feedback only (control); (2) physician-level financial incentive plus audit and feedback; (3) group-level financial incentive plus audit and feedback; and (4) physician- and group-level financial incentives and audit plus feedback (combined incentive).

The parent trial tested the impact of financial incentives (using the 4 arms described above) on improvements in 3 hypertension performance measures based on national guidelines (prescription of guideline-recommended medication, blood pressure control, and appropriate clinical response to uncontrolled blood pressure). A study protocol detailing the design and methods of this project has been published elsewhere.18 Performance data in the parent trial were collected via patient chart review. To assess the individual attitudes, cognitions, and interactions of interest in the current study, we surveyed and interviewed participating physicians at multiple time points to explore their commitment to meeting guideline-recommended hypertension management goals and improvement strategies. This mixed-methods design allowed quantitative attitudinal data to be linked to the chart review data to explore causal pathways between financial incentives and performance, and to qualitative data to gain a richer understanding of how these attitudes and explanatory phenomena manifest themselves in clinic settings.


We recruited 83 primary care physicians (approximately 7 from each site) who reported a full-time equivalent of at least 0.60 (approximately 3 days per week related to clinical activities) or had a primary care panel size of at least 500 patients (Table 1).


Goal Commitment. Hollenbeck and colleagues’ 7-item Likert-type scale19 was used to measure goal commitment as part of the audit and feedback process (Appendix A). This measure is widely used in the organizational literature; reported reliability is 0.71.19

Knowledge and Attitudes About Guidelines. One possible confounder of goal commitment levels is previous knowledge and attitudes about hypertension management; for example, if participants hold negative views about the utility or appropriateness of the guidelines for managing hypertension, goal commitment would be unduly low. To account for confounders, participants completed a knowledge and attitudes questionnaire after viewing an educational presentation on the JNC 7 Hypertension Guidelines (see Provider Education section below). The questionnaire included questions about prior awareness and understanding of the JNC 7 guidelines, agreement with its recommendations, and self-reports of whether the respondents apply the guidelines’ recommendations. Participants also completed a demographics survey upon enrollment. Appendix A presents both questionnaires.

Planning Quality. Because goal commitment is associated with improvements in planning behaviors, which lead to improved performance, we sought to qualitatively identify participants’ planning and improvement strategies in hypertension care. We used the taxonomy of Smith et al,20 who posit 7 characteristics indicative of high-quality planning efforts: (1) clear definitions of roles and functions; (2) systematic strengths, weaknesses, opportunities, and threats analysis; (3) development of action plans; (4) communication of action plans; (5) extensive interaction among team members; (6) allocation of resources; and (7) future orientation (ie, thinking longer term). The more of these characteristics that are present in planning efforts, the higher the quality of those efforts. Allocation of resources and future orientation

are the characteristics most likely to lead to actual changes in behavior; we coded for evidence of these characteristics in our interviews as our means of assessment.

Intervention Components

Provider Education. All participants received a standardized, web-based presentation summarizing the JNC 7 guidelines and educating participants about their study arm assignment and the study performance measures. A question and answer session followed. All participants also received pocket cards summarizing the JNC 7 guidelines and the study performance measures. The study website contained links to this presentation, pocket card, other JNC 7 resources, and patient resources for lowering blood pressure.

Financial Incentives. Participants in the intervention arms received payments approximately every 4 months over a 20-month intervention period. Incentive payments rewarded participants for chart-documented care of hypertensive patients (ie, prescribing guideline-recommended antihypertensive medications, providing guideline-recommended responses to uncontrolled blood pressure, and blood pressure control; see Petersen et al18 for chart abstraction and criterion data collection process details). In the individual arm, each physician received a direct payment based on his/her guideline adherence. In the group arm, a payment based on the collective performance of the participating physicians in the group was divided equally among all group members (both physicians and nonphysicians). In the combined arm, each physician received a direct payment based on his/her adherence; additionally, a payment based on the overall adherence of the physicians in the group was divided equally among all group members.

Audit and Feedback. Audit and feedback reports were delivered to participants in all 4 arms approximately every 4 months for 5 consecutive periods via a website. Reports were designed based on the tenets of Feedback Intervention Theory,21 using feedback characteristics found to improve feedback effectiveness in healthcare.22 The report showed the percentage of patients meeting each performance measure, the amount earned for meeting each measure (incentive arm reports only), and performance goals for the following period, a feature shown to improve feedback effectivenesss21,23 but no  often found in feedback reports (see Appendix B for a sample feedback report and graph of performance over time). The participants’ goal was to reach a benchmark based on the top performers in the previous period.24 We tracked participant visits to the feedback reports to identify who viewed their report and thus had the opportunity to cognitively link their earnings to their performance.


Human Subjects and Informed Consent.
We obtained institutional review board approval at each of the 12 sites in the study. We followed the approval requirements for the most conservative institutional review board to secure approvals at all sites.25

Surveys. Physicians completed 3 surveys: (1) a demographics survey upon enrollment in the study; (2) a knowledge and attitudes survey about the JNC 7 hypertension guidelines, administered as part of their provider education; and (3) a postfeedback survey containing the goal commitment measure of Hollenbeck et al, completed after receipt of each audit and feedback report. This survey also served to check that participants read their reports.

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